306003954-6-7-2024-22-AS-JHAY-D5ZRWA-20240607132250

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003954
Report Date: 06/07/2024
Date Signed: 06/07/2024 01:22:59 PM

Document Has Been Signed on 06/07/2024 01:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	PILGRIMS GUEST HOME		FACILITY NUMBER:	306003954
ADMINISTRATOR:	NORMITA/JOSE VIBAR		FACILITY TYPE:	740
ADDRESS:	8431 SANTA BERTA WAY		TELEPHONE:	(714) 995-4020
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY:	6	CENSUS: 3	DATE:	06/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Normita Vibar		TIME COMPLETED:	01:35 PM

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Licensing Program Analysts (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA Haley was greeted and granted entry by staff and explained the reason for the visit. Staff contacted Licensee/Administrator Normita Vibar who arrived a short time later and was present for the remainder of the of the visit.

During the inspection, LPA Haley observed all resident bedrooms and bathrooms. All resident bedrooms had the necessary elements and were in compliance with regulation guidelines.

Resident bathrooms were clean and organized. Hot water temperatures were measured in the range of 111.2 degrees Fahrenheit and 114 degrees Fahrenheit. No hazardous items were observed in the resident bathrooms, and all grab bars were tightly secured to the wall. There’s a locked closet in the hallway with emergency items prepared and ready to go. An emergency food and water supply was observed as well. There was another cabinet in the hallways with a supply of linens, and the carbon monoxide detector is mounted on the ceiling in the hallway.

The kitchen was clean and organized. Knives and sharp objects are kept locked in a drawer near the sink. A perishable food supply that meets regulation requirements was observed in the refrigerator. A non-perishable food supply that meets regulation requirements was observed in the cabinets. Resident medications are locked in a cabinet. There’s a small laundry area in between the kitchen and the backyard exit and bathroom with a washer and dryer. There is a locked cabinet with hazardous cleaning chemicals and laundry detergents. There’s a fully charged fire extinguisher mounted on the wall in the laundry area.

In between the living room and the backyard there’s an addition room. The room is used as an activity room and private visiting area if needed. In the activity room, there’s a locked cabinet used to store staff and resident files, and resident P&I funds.

Continued on LIC809C

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PILGRIMS GUEST HOME	FACILITY NUMBER: 306003954
	VISIT DATE: 06/07/2024

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The garage is used to store various items. There were clear walkways and in the middle of the garage there were several boxes and other items being stored. There's a deep freezer with an additional perishable food supply, and an additional non-perishable food supply observed on the shelves. There was a locked cabinet with an additional supply of hygiene items, and some hazardous cleaning items.

The backyard was clean, organized, and walkways were free of obstruction. Two shaded patio areas with tables and chairs were observed. One of two side exit gates is self closing and self latching.

An emergency evacuation drill was conducted March 5, 2024 and will continue to be conducted quarterly for staff on each shift. Smoke detectors, and the carbon monoxide detector tested operational.

During the visit an audit of all resident medications and P&I funds was completed.

No deficiencies are being cited as a result of today’s visit.

An exit interview was conducted, and a copy of this report was provided to Licensee/Administrator Normita Vibar.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC809 (FAS) - (06/04)

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